2013 Psychiatric CPT Code Update: Implementing E&M Codes ...
Transcript of 2013 Psychiatric CPT Code Update: Implementing E&M Codes ...
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2013 Psychiatric CPT Code Update: Implementing E&M Codes Into Daily Practice
APNA WebinarDecember 7, 2012
Mary D Moller
I have no conflict of interest or commercial support to disclose.
Objectives• Explain the outpatient practice impact for
psychiatric mental health nursing of changing the primary billing codes from psychotherapy codes to evaluation and management codes
• Discuss outpatient utilization of evaluation and management processes related to history, physical exam, and medical decision-making for billing and documentation of psychiatric care using a case study format
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Don’t Panic!• With a little study and practice you will get
this!
http://www.amazon.com/Standard-Edition-Current-Procedural-Terminology/dp/1603596836/ref=sr_1_1?ie=UTF8&qid=1354503944&sr=8-1&keywords=2013+cpt+professional+edition+spiral
Evaluation and Management Codes
• Start with a “99” compared to “908”• Used to document what happens in a patient
encounter-rendering a medical service• Evaluation
– (collecting and assessing information) and
• Management– (planning treatment or further assessment;
prescribing medication)
• Used by all other medical providers
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Types of Patients• New Patient
– New to practice– Not seen in the past 3 years
• Established Patient– Ongoing relationship with the practice– Have seen in the past 3 years– If you are covering for another provider, the
patient is considered seen
Descriptions of E&M SessionsAn entirely new vocabulary!!!
Sessions are described in levels:1. Level 1= Minimal-no MD/APRN required2. Level 2= Problem-focused 3. Level 3= Expanded problem-focused4. Level 4= Detailed5. Level 5= Comprehensive• Most visits are Level 4 and Level 5• They are not timed—you could have a level 4 in
just 20-30 minutes
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3 Broad Categories of Components in an E&M Visit
• History• Physical exam• Medical decision-making
• Always start with medical decision-making to determine the extent of history and physical exam you will need to do
Medical Decision-Making (MDM):3 Components
1. Number of diagnoses or management options• Based on problem points chart developed for
audit purposes because language is so ambiguous
2. Amount of complexity of data• Based on data points chart developed for audit
purposes because language is so ambiguous
3. Risk of significant complications, morbidity, and/or mortality
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Number of Diagnoses or Management Options
• Based on– Number and types of problems– Complexity of establishing a diagnosis– Management decisions
• Influenced by– Undiagnosed problems– Number and type of tests– Need to seek advice from others– Problems worsening or failing to respond
Number of Diagnoses or Management Options-Problem Points
Category of Problems/Major New symptoms Points per problem
Self-limiting or minor (stable, improved, or worsening) (max=2) 1
Established problem (to examining physician); stable or improved 1
Established problem (to examining physician); worsening 2
New problem (to examining physician); no additional workup or diagnostic procedures ordered (max=1)
3
New problem (to examining physician); additional workup planned* 4
*Additional workup does not include referring patient to another physician for future care
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Levels of Number of Diagnoses or Management Options
Level Total Data PointsMinimal 0-1Limited 2Multiple 3Extensive 4
Amount and/or Complexity of Data• Based on
– Types of diagnostic tests– Need to obtain records– Need to obtain history from other sources
• Influenced by– Unexpected findings– Independent interpretation of images, specimens,
etc– Discussion of results with physician performing
test
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Amount and Complexity of Data:Data Points
Categories of Data to be Reviewed (max=1 for each) Points
Review and/or order of clinical lab tests 1
Review and/or order of tests in the radiology section of CPT 1
Review and/or order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than patient
1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
2
Independent visualization of image, tracing, or specimen itself (not simply review report)
2
Amount and/or Complexity of Data to be Reviewed
Level Total Data PointsMinimal or none 0-1Limited 2Multiple 3Extensive 4
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Risk to the Patient• Based on
– Presenting problem– Diagnostic procedure– Management options
• Influenced by– Co-morbidities, underlying conditions, risk factors– Uncertain prognosis, exacerbations,
complications– Decision to order prescription drugs, IV meds– Decision to perform invasive tests, procedures,
major surgery
Level of Risk DeterminationLevel
of Risk *
Presenting Problems Diagnostic Procedure
Management Options Selected
Minimal Risk
• One self-limited or minor problem, e.g., dysthymia well-managed
• Laboratory tests
• Chest X-rays• EKG/EEG• Urinalysis
• Rest• Stay home
from school
Low Risk
• Two or more self-limited or minor problems;
• One stable chronic illness;• Acute uncomplicated
illness
• Physiologic tests not under stress, e.g., PFTs
• Glucosemonitoring
• OTC drugs
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Level of Risk DeterminationLevel of Risk *
Presenting Problems Diagnostic Procedure
Management Options Selected
Mod Risk
• One or more chronic illnesses with mild exacerbation,
• progression, or side effects;• Two or more stable chronic
illnesses;• Undiagnosed new problem with
uncertain prognosis;• Acute illness with systemic
symptoms
• None that would be done in out-patientpsychiatry!
• Prescription drug management
High Risk
• One or more chronic illnesses with severe exacerbation, progression, or side effects;
• Acute or chronic illnesses that pose a threat to life or bodily function
• None that would be done in out-patient psychiatry!
•Drug therapy requiring intensive monitoring fortoxicity (clozapine)
Selecting the Level of Outpatient Medical Decision-Making*
# Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or morbidity/ mortality
DESIGNATED LEVEL OF MEDICAL DECISION-MAKING
Minimal [0-1 problem points
Minimal or none[0-1 data points]
Minimal STRAIGHTFORWARD99202-99212
Limited [2 problem points]
Limited [2 data points]
Low LOW COMPLEXITY99203-99213
Multiple[3 problem points]
Multiple[3 data points]
Moderate MOD COMPLEXITY99204-99214
High complexity[4 problem points]
Extensive[4 data points]
Extensive HIGH COMPLEXITY99205-99215
*Requires 2 out of 3 areas in the outpatient office setting
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Documentation of Medical Decision-Making
• Assessment, impression, diagnosis
• Status of established diagnosis
• Differential diagnosis, probable, etc for undiagnosed (rule-outs)
• Initiation/changes in treatment
• Referrals, request, advice
• Type of tests
• Review and findings of tests
• Relevant findings from records
• Discussion of test results
• Direct visualization of specimens, images, etc
• Comorbidities/underlying conditions
• Type of surgical or invasive procedure
ONCE YOU HAVE DECIDED THE MDM…. THEN………
PROCEED TO HISTORY AND EXAM!!!
http://www.aafp.org/fpm/2001/1000/f
pm20011000p43-uf1.gif
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HISTORY
Chief Complaint (CC)History of Present Illness (HPI)Review of Systems (ROS)Past, Family, Social History (PFSH)
Chief Complaint
• Document in patient’s words – “I feel like life isn’t worth living at all anymore”
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History of Present Illness• 8 Descriptors
– Location (emotional and behavior are types of location in psychiatry
– Quality (description of symptom i.e. sadness)– Severity– Duration– Timing– Context– Modifying Factors– Associated signs/symptoms
HPI Example in One Sentence!The patient reportsongoing4 emotional2
problems of moderate3
anger4 starting with thediscovery of spousal marital affair5 two weeks ago6, now does not want to live in the same house7 andassociated with disruptedsleep and loss of appetite8.
1. Timing2. Location 3. Severity4. Quality5. Context6. Duration7. Modifying Factors8. Associated
signs/symptoms
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Levels of HPILevels of History of Present Illness
Brief 1-3 elements ORStatus of 1-2 chronic or inactive conditions
Extended 4 or more elements ORStatus of 3 or more chronic or inactive conditions
1. Location
2. Quality
3. Severity
4. Duration 5
5. Timing
6. Context
7. Modifying Factors
8. Associated Signs/Symptoms
Past, Family, Social History (PFSH)• Past history
– Current medications– Illnesses and injuries– Operations and hospitalizations– Allergies– Treatments– Dietary status– Age appropriate immunizations
• Family history– Medical events in patient’s
family r/t CC, HPI, ROS– Hereditary or high risk diseases– Health status or cause of death
of parents, siblings, children
• Social History– Marital status– Living arrangements– Occupational history– Use of drugs, alcohol,
tobacco– Extent of education– Sexual history– Current employment– Other
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Levels of Past, Family, Social History
Levels of PFSHPertinent 1 item from 1 of 3 areasComplete New Patient: 3 out of 3 areas
Established Patient: 2/3 areas
Review of Systems
1. Constitutional2. Eyes3. Cardiovascular4. Neurological5. Genitourinary6. Ears, nose, throat,
mouth7. Gastrointestinal
8. Integumentary (skin and/or breast
9. Musculoskeletal10.Psychiatric11.Hematologic/lymphatic12.Respiratory13.Endocrine14.Allergic/immune
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Review of Systems RequirementsReview of Systems Requirements
Problem pertinent:
System directly related to the problem(s) identified in the HPI
Extended: 2-9 systems
Complete: 10 or more systems • Document individually systems with
positive or pertinent negative responses• “All other systems reviewed and are
negative” is permissible• In the absence of such a notation, at
least 10 systems must be individuallydocumented
Levels/Types of HistoryHPI PFSH ROS TYPE
Brief: 1-3 elements or 1-2 chronic conditions
N/A N/A Problem-focused99202/99212
Brief: 1-3 elements or 1-2 chronic conditions
N/A Problem Pertinent
1
Expanded problem-focused
99203/99213
Extended: 1-3 elements or 1-2 chronic conditions
Pertinent1 element*
Extended2-9
systems
Detailed99204/99214
Extended: 4 elements or 3 chronic conditions
Complete3 elements**
Complete10-14
systems
Comprehensive99205/99215
*No PFSH required with subsequent hospital visits **2 elements for established patients
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Physical Exam
Physical ExamUse 1997 Revision for Single System Exam
1. Cardiovascular2. Ears, nose, mouth and
throat3. Eyes4. Genitourinary (female)5. Genitourinary (male)6. Hematologic, Lymphatic,
Immunologic
7. Musculoskeletal8. Neurological9. Psychiatric10.Respiratory11.Skin
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Psychiatric Single System• Comprised of the following systems
– Constitutional (Shaded border) [8 bullets]– Musculoskeletal (Unshaded border) [2 bullets]– Psychiatric (Shaded border) [11 bullets]
• Shaded Border refers to complete descriptions of each single system exam occurring in the CPT Manual.
ConstitutionalConstitutional (shaded border)
• Measurement of any 3 of the 7 vital signs: —B/P__ sitting or standing, —B/P__ supine, —P__, —R__, —T__, —Ht__ —Wt__
• General appearance-grooming, deformities• Development• Nutrition
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Musculoskeletal
• Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic,) with notation of any atrophy and abnormal movements– e.g. motor tics, tremors, vermiform tongue
movements)
• Examination of gait and stations
Psychiatric• Description of speech including: rate; volume; articulation;
coherence; and spontaneity with notation of abnormalities (eg, perseveration, paucity of language)
• Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation
• Description of associations (eg, loose, tangential, circumstantial, intact)
• Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
• Description of the patient’s judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition)
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Complete Mental Status Exam Including Cognitive Function
• Orientation to time, place and person• Recent and remote memory• Attention span and concentration• Language (eg, naming objects, repeating
phrases)• Fund of knowledge (eg, awareness of current
events, past history, vocabulary)• Mood and affect (eg, depression, anxiety,
agitation, hypomania, lability)
Psychiatric Examination:Number of Required Elements
Elements of Examination Level1-5 bulleted elements Problem-focused
99202, 99212
At least 6 bulleted elements Expanded problem-focused99203, 99213
At least 9 bulleted elements Detailed99204, 99214
Perform all bulleted elements in shaded border sections AND1 element from non-shaded border
Comprehensive99205, 99215
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The Element of TIME
Use When Counseling and Coordination of Care Comprises
Over 50% of the Encounter
Time• Normally you do not have to document time• The E&M system rewards efficiency, you
can have a level 5 in less than 30 minutes depending on the situation
• We code based on work done, not time spent……EXCEPT FOR
• THE COUNSELING AND COORDINATION OF CARE EXCEPTION
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Counseling and Coordination of Care• Time becomes the controlling factor
– Face-to-face time for office visits– Unit time for facility visits
• Document– Length of time of the encounter and of the
time spent in counseling and coordination of care
– The counseling and/or coordination of care activities-include family members present
Examples of Counseling Discussions
• Diagnostic results • Impressions• Recommended diagnostic studies• Prognosis• Risks and benefits of management options• Instructions for management and/or follow-up• Importance of compliance with chosen
management options• Risk factor reduction• Patient and family education
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Time-based Code for Counseling/Coordination
• 99212= 10 minutes• 99213= 15 minutes• 99214= 25 minutes• 99215= 40 minutes
OFFICE OR OTHER OUTPATIENT SERVICES: New or Establi shed99201/99211 99202/99212 99203/99213 99204/99214 99205/99215
HISTORYCC Required Required Required Required RequiredHPI 1-3 elements 1-3 elements 4+ elements 4+elements 4+ elementsROS N/A Pertinent 2-9 systems 10-14
systems10-14 systems
PFSH N/A N/A 1/3 elements 3/3 elements 3/3 elements
PHYSICAL EXAM1997 1-5 elements 6-8 elements 9 or more
elementsComprehensive
Comprehensive
MEDICAL COMPLEXITY DECISION MAKINGSF SF LOW MODERATE HIGH
COUNSELING/COORDINATION OF CAREFace to face
10 minutes 15 minutes 25 minutes 40 minutes
SUMMARY OF ALL WE HAVE COVERED!
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Putting It All Into Practice
EVALUATION AND MANAGEMENT NEW PATIENT OFFICE PROGRE SS NOTE Client Name:___________________________ Date of Service:_______________ Provider Name:______________________Time In:_____________am/pm Time Out:________________ am/pm Total Time Spent (minutes):_____________________Level of Service: 99202______ 99203______99204______99205_____ COUNSELING/COORDINATION>50% of time (explain)______________________________________________________________________________________________________________________________CHIEF COMPLAINT:
PFSH No Chng See Note
Past □ □Family □ □Social □ □99202-PROBLEM FOCUSED=NONE 99203-EXPANDED PROBLE M FOCUSED=NONE 99204-DETAILED=At Least 1 Item From 1 Category 992 05-COMPREHENSIVE Specifics of at Least Two Items
EXAM-Single System 2 BULLETS NL See Note EXAM –Single System 2 BULLETS NL See Note
• 3 out of 7 Constitutional □ □ Musculoskeletal □ □
Blood Pressure: • Gait and station □ □
Pulse: • Muscle strength or tone, atrophy, □ □
abnormal movements (e.g. flaccid, cog wheel)Temperature:
Respiration:
Height: Note:
Weight:
• General appearance of patient □ □
(e.g. development, nutrition, body habits, deformities, □Well Groomed □ Disheveled □ Bizarre □ Inappropriate
Note:
Please refer to your handouts for the remaining discussion
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99213-Established Patient
• Office visit for a 32-yo MHF with major depression, moderate, without psychotic features who is stable six months on an SSRI who wants to decrease her current dosage due to sexual dysfunction.
Selecting the Level of Outpatient Medical Decision-Making*
# Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or morbidity/ mortality
DESIGNATED LEVEL OF MEDICAL DECISION-MAKING
Minimal [0-1 problem points
Minimal or none[0-1 data points]
Minimal STRAIGHTFORWARD99202-99212
Limited [2 problem points]
Limited [2 data points]
Low LOW COMPLEXITY99203-99213
Multiple[3 problem points]
Multiple[3 data points]
Moderate MOD COMPLEXITY99204-99214
High complexity[4 problem points]
Extensive[4 data points]
Extensive HIGH COMPLEXITY99205-99215
*Requires 2 out of 3 areas in the outpatient office setting
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Levels/Types of HistoryHPI PFSH ROS TYPE
Brief: 1-3 elements or 1-2 chronic conditions
N/A N/A Problem-focused99202/99212
Brief: 1-3 elements or 1-2 chronic conditions
N/A Problem Pertinent
1
Expanded problem-focused
99203/99213
Extended: 1-3 elements or 1-2 chronic conditions
Pertinent1 element*
Extended2-9
systems
Detailed99204/99214
Extended: 4 elements or 3 chronic conditions
Complete3 elements**
Complete10-14
systems
Comprehensive99205/99215
*No PFSH required with subsequent hospital visits **2 elements for established patients
99213-HPI ExampleThe patient reportsongoing1 decreased libido2
creating moderate3
frustration4 that has been going on for the last 6 weeks5. Now that her depression is better she wants an active sex life6 . Her husband is supportive and not pressuring her7.
[There is no #8)
1. Timing2. Location 3. Severity4. Quality5. Duration6. Context7. Modifying Factors8. Associated
signs/symptoms
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99213-History
• Only need 1-3 elements but we have 7 as we capture her CC.
• No PFSH required in a 99213• ROS is problem-specific-evaluate
psychiatric status
Psychiatric Examination:Number of Required Elements
Elements of Examination Level1-5 bulleted elements Problem-focused
99202, 99212
At least 6 bulleted elements Expanded problem-focused99203, 99213
At least 9 bulleted elements Detailed99204, 99214
Perform all bulleted elements in shaded border sections AND1 element from non-shaded border
Comprehensive99205, 99215
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99213-Exam
• 6 bulleted items from psychiatric exam-one from constitutional. No musculoskeletal needed– Psychiatric: Speech, thought process,
associations, thought content, judgment – Constitional: Appearance
99213 Progress Note• CC: 32 yo MHF. Follow up visit for treatment of major depression,
stable on SSRI for 6 months, experiencing decreased libido the last 6 weeks.
• HPI: No current symptoms of depression, experiencing decreased libido.
• ROS: Psychiatric - No symptoms of depression or anxiety.• PE: Appearance: appropriately dressed, verbal and cooperative;
Speech: normal rate and tone; Mood and affect: euthymic, full and appropriate; Thought: process logical, associations intact, no SI/HI
• Impr: Major depression responding to SSRI• Plan: Decrease fluoxetine from 40mg to 20mg. Called pharmacy
with change.• Return visit in 1 month.
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99214-Established Patient
Office visit for a 52 year-old male, with a 16 year history of bipolar disorder responding to lithium carbonate and brief insight-oriented psychotherapy. Patient reports tremors and some diarrhea. Psychotherapy and prescription provided. Ordered labs.
99214 Outpatient Medical Decision-Making*
# Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or morbidity/ mortality
DESIGNATED LEVEL OF MEDICAL DECISION-MAKING
Minimal [0-1 problem points
Minimal or none[0-1 data points]
Minimal STRAIGHTFORWARD99202-99212
Limited [2 problem points]
Limited [2 data points]
Low LOW COMPLEXITY99203-99213
Multiple[3 problem points]
Multiple[3 data points]
Moderate MOD COMPLEXITY99204-99214
High complexity[4 problem points]
Extensive[4 data points]
Extensive HIGH COMPLEXITY99205-99215
*Requires 2 out of 3 areas in the outpatient office setting
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Levels/Types of History
*No PFSH required with subsequent hospital visits **2 elements for established patients
HPI PFSH ROS TYPE
Brief: 1-3 elements or 1-2 chronic conditions
N/A N/A Problem-focused99202/99212
Brief: 1-3 elements or 1-2 chronic conditions
N/A Problem Pertinent
1
Expanded problem-focused
99203/99213
Extended: 1-3 elements or 1-2 chronic conditions
Pertinent1 element*
Extended2-9
systems
Detailed99204/99214
Extended: 4 elements or 3 chronicconditions
Complete3 elements**
Complete10-14
systems
Comprehensive99205/99215
99214-History
• Only need 4 elements but we have 8 as we capture the CC.
• 1 element of PFSH required in a 99214• ROS is detailed for 2-9 systems
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Psychiatric Examination:Number of Required Elements
Elements of Examination Level1-5 bulleted elements Problem-focused
99202, 99212
At least 6 bulleted elements Expanded problem-focused99203, 99213
At least 9 bulleted elements Detailed99204, 99214
Perform all bulleted elements in shaded border sections AND1 element from non-shaded border
Comprehensive99205, 99215
99214-Exam
• 9 bulleted items from any of the areas:– Psychiatric: Speech, thought process,
associations, thought content, judgment, mood
– Constitutional: vital signs, weight, general appearance
– Musculoskeletal: gait and station
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99214 Progress Note• CC: 52 yo SWM. Scheduled visit for treatment of bipolar disorder,
stable on lithium for 16 months. Complains of tremors and diarrhea.• HPI: The patient reports increased tremors and diarrhea creating
moderate difficulty with fine motor tasks and fear of not being around a bathroom that has been going on for the last 3 weeks. This has happened since having the ‘bad GI flu’. He has decreased his salt and fluid intake but continued his lithium. He is also feeling dizzy. He is concerned he won’t be able to work.
• ROS: (Required only 2 systems)– Psychiatric: reports no change in mood, thinking, speech, continued taking
lithium while had the flu– Constitutional: reports changes in diet after experiencing fever, nausea,
vomiting and diarrhea for 4 days. – GI: reports ongoing diarrhea after getting over the flu– Musculoskeletal: complains of tremors and weakness upon getting up too fast
99214 Progress Note• PE: (9 elements)
– Psychiatric: Appearance: appropriately dressed, verbal, and cooperative, Attitude cooperative, speech clear with no slurring or increased rate, thought process and associations normal, thought content normal with no grandiosity, judgment adequate, mood euthymic
– Constitutional: B/P= 168/110, P=92, R=18, T=99, weight=224 (increase of 10#), well-groomed with good hygiene
– Musculoskeletal: normal strength, fine tremors observable in both extremities that have never occurred before, gait normal
• Impr: Bipolar disorder, stable. Mild lithium toxicity related to continuing lithium while experiencing vomiting and diarrhea, possible dehydration.
• Plan: Continue lithium and therapy. Called lab and ordered stat lithium level, CMP, renal function, thyroid function. Reviewed diet and instructed to return to normal diet and increase water intake back to normal 2 liters/day. Reviewed effects of lithium during dehydration
• Call patient with lab results. Return visit in 2 weeks to recheck vitals.
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99215-Established Patient
• Office visit for 25 year-old male with a history of schizophrenia who has been seen bi-monthly and is partially compliant with medications but is complaining of new onset of auditory hallucinations.
Selecting the Level of Outpatient Medical Decision-Making*
# Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or morbidity/ mortality
DESIGNATED LEVEL OF MEDICAL DECISION-MAKING
Minimal [0-1 problem points
Minimal or none[0-1 data points]
Minimal STRAIGHTFORWARD99202-99212
Limited [2 problem points]
Limited [2 data points]
Low LOW COMPLEXITY99203-99213
Multiple[3 problem points]
Multiple[3 data points]
Moderate MOD COMPLEXITY99204-99214
High complexity[4 problem points]
Extensive[4 data points]
Extensive HIGH COMPLEXITY99205-99215
*Requires 2 out of 3 areas in the outpatient office setting
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Levels/Types of HistoryHPI PFSH ROS TYPE
Brief: 1-3 elements or 1-2 chronic conditions
N/A N/A Problem-focused99202/99212
Brief: 1-3 elements or 1-2 chronic conditions
N/A Problem Pertinent
1
Expanded problem-focused
99203/99213
Extended: 1-3 elements or 1-2 chronic conditions
Pertinent1 element*
Extended2-9
systems
Detailed99204/99214
Extended: 4 elements or 3 chronic conditions
Complete3 elements**
Complete10-14
systems
Comprehensive99205/99215
*No PFSH required with subsequent hospital visits **2 elements for established patients
99215-History
• Only need 4 elements but we have 8 as we capture the CC.
• 2 elements of PFSH required in a 99215• ROS is comprehensive: >10 systems
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Psychiatric Examination:Number of Required Elements
Elements of Examination Level1-5 bulleted elements Problem-focused
99202, 99212
At least 6 bulleted elements Expanded problem-focused99203, 99213
At least 9 bulleted elements Detailed99204, 99214
Perform all bulleted elements in shaded border sections AND1 element from non-shaded border
Comprehensive99205, 99215
99215 Progress Note• CC: 25 yo SWM. Scheduled visit for treatment of schizophrenia.
Reports new onset of persecutory auditory hallucinations.• HPI: The patient reports new increased auditory hallucinations
creating severe difficulty because of persecutory nature that has been going on for the last 3 weeks. He has never heard these kinds of voices before. This has happened since increasing marijuana intake to 3 x daily. He has moved into new supported living that has drug dealers there. He is also feeling lethargic and is afraid to answer the telephone. His family insisted he come in for an appointment and brought him to the session.
• ROS: (Required 10 systems): Psychiatric – anxious, paranoid, unable to maintain eye contact, reluctant to engage in conversation, frequently turns head and mumbles to unseen voices. Appearance disheveled and unkempt, strong body odor, fingers stained yellow from smoking, hasn’t eaten in 2 days. All other systems reviewed and are negative.
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99215 Progress Note• PE: (all bullets in constitutional and psychiatric and 1 bullet in
musculoskeletal)– VS: BP 140/90, pulse 90 and regular, R 20; Appearance: unkempt, does not
initiate conversation, cooperative; Speech: soft, slowed, mumbles; Mood and affect: sad, restricted, incongruent; Thought: process illogical, paranoid, associations intact, no SI, no HI, persecutory aud hall. Ideas of reference; Ox2; recent and remote memory: inpaired; J&I: poor; Gait and station: WNL; attention and concentration impaired; language: good; fund of knowledge: poor.
• Impr: schizophrenia in exacerbation related to substance use and medication non-adherence. Unable to care for self (corroborated by family).
• Plan: Temporarily move home with family to monitor substance use, assist with medication administration and ADLs. Contact ACT team, refer family to NAMI, obtain case management prior to going back to apartment. Return visit in 2 weeks.
99215-Established PatientCounseling and Care
Coordination
• Based on time.
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References• 2013 CPT Coding Manual• AACAP online webinars permission granted
to APNA• E/M University Online:
http://emuniversity.com/Curriculum_Free.html• Medicare learning network:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf